Myofascial Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: This patient is a 49-year-old female with a history of refractory migraine and myofascial pain dating back to her multiple motor vehicle accidents in 1987. She states that the muscle pain can trigger her migraines. The patient achieves relief of her migraines with Relpax, but is requiring treatment often (1-2 times per week). Prior preventive treatments have failed including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants, though no specific mention is made of any trials of migraine preventives. Physical medicine measures have apparently not relieved the patient’s myofascial pain either. The Health Plan has denied the patient’s request for authorization of Botox injections due to their determination that the therapy is experimental/investigational in nature.The patient’s myofascial pain is refractory, and standard pain management approaches have failed.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lidocaine infusions. Chronic pain is a debilitating condition that is challenging to treat and a multimodal approach to treatment is required. Researchers report that lidocaine provides central and peripheral analgesia and has a low side effect profile, making it a useful option in chronic pain management. A retrospective study concluded that lidocaine infusions are a safe and effective treatment for chronic neuropathic pain conditions. Similarly, another study concluded that lidocaine infusions are effective for patients with chronic pain who suffer from fibromyalgia. Overall, lidocaine infusions are an effective and evidence-based treatment option for various chronic pain syndromes.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet 10 mg (one tablet every four hours) and/or morphine ER 30 mg (one tablet every four hours), and if not, Percocet 10 mg (one tablet every six hours) and/or morphine ER 30 mg (one tablet every six hours).Findings: The physician reviewer found that a review and meta-analysis evaluating opioid use for the treatment of patients with chronic non-cancer pain concluded that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. However, the authors did not find that opioids were superior to non-opioid therapy for non-cancer pain.

Findings: The physician reviewer found that a patient with a diagnosis of lumbar spinal stenosis and myofascial pain has requested authorization and coverage for administration of spinal injections at up to four levels of the spine, including the cervical region, thoracic region, and lumbar region, in addition to trigger point injections (10 points) to be co-administered on the same date of service and scheduling of the injection appointments on an “as needed” basis based upon the patient’s severe pain and request for repeat injection(s). The records indicate that the patient has previously received trigger point injections that have included corticosteroids; the medical necessity and safety of the high number and volume of corticosteroid injections that might be administered with the requested injections on the same day is not clearly established.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving myofascial pain, then check the rights and deadlines that apply to your plan.